Patient Name
*
First Name
Last Name
Care Card Number
*
Email
*
example@example.com
Reason for this visit (what is your immediate concern)?
Previous dentist (name & location)?
Date of last dental visit and treatment provided at that time?
Have you had any recent dental x-rays taken? If so, where & when? Can we request they be sent to our office?
Are you nervous about receiving dental treatment?
Have you ever had complications from past dental treatment?
Have you ever had trouble getting numb of had any reactions to local anesthetic?
How often do you brush and floss your teeth? (Do your gums bleed while brushing or flossing)?
Do you have any sores or lumps in or near your mouth?
Have you ever had any head, neck or jaw injuries?
Do you have problems with your jaw joint (pain, sounds, limited opening, locking or popping)
Do you clench / grind your teeth? If so, do you or have you ever work a bite appliance?
Do you wear dentures or partials? If yes, date of placement.
Do you have dental implants? If yes, date of completion.
Have you had orthodontic treatment? If yes, date of completion.
Have you ever been treated for periodontal disease or visited a periodontal specialist?
Are you happy with the appearance and function of your teeth?
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